ALDERSGATE COLLEGE NCM 107A

SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

Module 5: The Normal Puerperium/Postpartum

OVERVIEW: The module discusses topics related to the normal puerperal period without associated complications.

General Objective:
At the end of the course, the students should have acquired the knowledge, skills and attitudes required in the care
for the normal mothers in the puerperal period and the application of principles and concepts on family and family
health nursing process.

Objectives:
1. To apply the knowledge on the approaches on the care of the woman in the puerperal period and the use of
Nursing Process
2. Prioritize nursing diagnosis.

Learning Focus
NURSING CARE OF THE NORMAL PUERPERIUM/ POSTPARTUM

PUERPERIUM – is the 6 week period following delivery in which the reproductive organs revert from a pregnant to a
non-pregnant state.

Systemic and Anatomic Changes

1. Reproductive System

A. Uterus

a. Involution of the Uterus – refers to the progressive changes in the uterus after the delivery leading to
its pre-pregnant size and condition. The normal process requires 5-6 weeks afterwards, the uterus
regains its norma size.
The weight of the uterus is as follows:
▪ 1,000 grams – immediate postpartum
▪ 500 grams – end of the first week
▪ 300 grams – end of the second week
▪ 100 grams or less – complete involution

The Mechanisms of Uterine Involution

Immediately after placental separation, the deciduas of the uterus is irregular, jagged and varies
in thickness
▼
Decreased estrogen and progesterone following placental separation
▼
Uterine cells atrophy

Note:
▪ Involution of placental site is a similar process but takes 6-7 weeks for completion.
▪ Rather than forming a fibrous scar in the deciduas, the placental sites heals by a process of
exfoliation.

Factors that enhance uterine involution:

▪ Uncomplicated labor and birth
ALDERSGATE COLLEGE NCM 107A
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

▪ Complete expulsion of the amniotic membranes and placenta

▪ Breastfeeding
▪ Manual extraction of placenta during CS
▪ Early ambulation
Factors that retard uterine involution
▪ Prolonged labor
▪ Anesthesia
▪ Dystocia
▪ Grand multiparity
▪ Full bladder
▪ Incomplete expulsion of the placental membranes
▪ Infection
▪ Overdistended uterus

b. Changes in the Fundal Positions – immediately after placental expulsion, the uterus contracts firmly
to the size of a grape fruit.

Fundal Positions
▪ After placental expulsion – midline of abdomen, ½ to 2/3 of the way between umbilicus and
symphysis pubis.
▪ 6-12 hours after birth – at the level of the umbilicus and it remains for about half a day.
▪ 1 day after birth – 1 cm below umbilicus
▪ 2 days to 2 weeks after birth – descends one finger breadth per day.
▪ 2 weeks – located on the pelvic area.
▪ 10-22 days – is the average time that the uterine fundus is no longer palpable.
Important Considerations:
▪ A fundus that is above the umbilicus and is boggy is associated with excessive uterine bleeding.
▪ When the fundus is higher than expected and deviated from the midline usually to the right,
suspect bladder distention.
▪ If a mother is breastfeeding, the release of oxytocin from the posterior pituitary gland in response to
sucking may hasten the return of the normal fundal position.

c. Lochia – are the vaginal discharges after delivery which should not contain blood clots and should be
minimal in amount.
Types:
▪ Lochia Rubra – is dark red in color, present for the first 1-3 days postpartum. It contains epithelial
cells, erythrocytes, leukocytes, shreds of deciduas and occasionally fetal meconium, lanugo and
vernix caseosa.
▪ Lochia Serosa – is pinkish to brownish in color, presents from 4-10 days post partum. It is
composed of “serous exudates”, shreds of deciduas, erythrocytes, leukocytes, cervical mucus and
numerous microorganism.
▪ Lochia Alba – is yellowish to whitish in color. It is present from 11-21 days postpartum. It
contains leukocytes, decidual cells, epithelial cells, fats, cervical mucus, cholesterol, crystals and
bacteria.
Important Considerations:
▪ Lochia should not contain large blood clots but small clots are normal
▪ Like the menses, it has a musty, stale odor that is not offensive.
▪ Microorganisms are always present and by the second day postpartum, the uterus is
contaminated with vaginal bacteria.
▪ Any foul smell suggests infection.
▪ Discharges are greater in the morning.
▪ The evaluation of the lochia is necessary to:
ALDERSGATE COLLEGE NCM 107A
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

- Determine the presence of hemorrhage

- Assess uterine involution

B. Vaginal Changes
▪ Following birth, it appears edematous and maybe bruised.
▪ Vaginal mucosa maybe pale and with rugae which may lead to dyspareunia.
▪ Tone and contractility of the vaginal opening maybe improved by Kegel’s Exercises.

C. Perineal Changes – early postpartal period, the soft tissue in and around the perineum may appear
edematous with some bruising.

D. Recurrence of Ovulation and Menstruation

▪ First cycle is unovulatory
▪ For non-lactating women, menses resume in 4-6 weeks.
▪ For lactating women, menses less predictable but may resume in 12-24 weeks.
▪ Lactating less than one month, menses resume in 4-6 weeks.

2. Abdomen – the stretched abdominal wall appears loose and flabby but will respond to exercise within 2-3
months. The stretch marks may take on different colors based on the mother’s skin.

3. Breast
a. Non-lactating mother
- Prolactin levels fall rapidly
- May still secrete colostrums for 2-3 days
- Engorgement of breast tissue from temporary congestion of veins and lymphatic circulation occurs
on the third days, lasts 24-45 hours usually resolves spontaneously.
b. Lactating mother
- High levels of prolactin immediately after delivery of placenta continued by frequent contact with the
nursing baby.
- Initial secretion of colostrums with increasing amount of true breastmilk appearing 48-96 hours.
- “Let-down Reflex” occurs caused by oxytocin from posterior pituitary released by sucking.

4. Gastrointestinal System
a. Hunger following birth is common.
b. The postpartum mother is frequently thirsty.
c. Sluggish bowel movements occur leading constipation.
d. For CS, she may experience flatulence.

5. Urinary Tract
a. Increased bladder capacity, swelling and bruising of tissues around the urethra.
b. Decreased sensitivity to fluid pressure and decreased sensation of bladder filling.
c. Women who had an anesthetic block have inhibited neural functioning of the bladder and are more
susceptible to bladder distention, difficulty voiding and bladder retention.
d. Urinary output increases 12-24 hours postpartum due to puerperal dieresis.
e. Women with pre-eclampsia, chronic hypertension and diabetes experience even greater fluid retention so
postpartal diuerisis is increased accordingly.
f. If urinary stasis occurs, there is increased risk of bacterial infection.
g. Hematuria due to bladder trauma may occur but maybe masked by lochia.
h. Acetone maybe present in the urine of women with diabetes or women with prolonged labor and
dehudration.

6. Vital Signs
a. After 24 hours postpartum, she should be afebrile; if it occurs still after 24 hours, suspect infection.
b. BP remains stable and within normal range after birth.
ALDERSGATE COLLEGE NCM 107A
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

▪ Decreased BP maybe due to decreased intrapelvic pressure or hemorrhage.

▪ Increased BP accompanied by headache suggests pre-eclampsia.
c. Bradycardia commonly occurs during the first 6-10 days postpartum.
d. Tachycardia occurs less frequently.

7. Blood Values
a. Blood values should return to pre-pregnant state by 6-9 weeks after birth.
b. Leukocytosis with WBC counts up to 30,000/ml persists in the early postpartal period.
c. Hemoglobin values and erythrocytes values should be appropriate or exceed pre-labor values within 2-6
weeks postpartum.
d. Hemoconcentration leading to rise in hematocrit occurs.
e. Anemia is a common postpartal complication with an incidence of greater than 50%.

8. Postpartal Chills and Diaphoresis

a. Postpartal chills are related to a neurologic response or to vasomotor changes.
b. Chills and fever later in the puerperium indicates infection.
c. Diaphoresis occurs at night.

9. After Pains
a. After pains occur more commonly in multis.
b. After pains may cause discomfort for 2-3 days postpartum.
c. The administration of oxytocin increases the discomfort.
d. Breastfeeding also increases the afterpains.
e. Analgesics could be given one hour before breastfeeding to relieve the discomfort.

Postpartal Psychological Adaptations

Psychological Phases
1. Taking-In Phase – occurs during the first two days characterized by passivity and dependence on others.
2. Taking- Hold Phase – occurs on the 2nd or 3rd day. The is now ready to resume control of her body.
3. Letting-Go Phase – the mother let’s go of the single life and starts the role of parenthood.

Maternal Role Attainment Stages

1. Anticipatory Stage – occurs during pregnancy. The woman looks to role models, especially her own mother.
2. Formal Stage – begins when the child is born. The woman is still influenced by the guidance of others and tries
to act as she believes others expects of her.
3. Informal Stage – begins when the mother begins to make her own choices about mothering. The woman begins
to develop her own style of mothering and finds ways of functioning that work well for her.
4. Personal Stage – is the final stage. She is already comfortable with the notion of herself as a “mother”

Postpartum Psychological Disorders (Normally occurs in the puerperium)

1. Adjustment Reaction with Depressed Mood (Postpartum Blues) – occurs in 50-70 % of mothers. It is the
transient period of depression that occurs in most women few days postpartum and may last for 10 days. It is
characterized by mild depression interposed with happier feelings. Note: This is more common to primis.

2. Postpartum Psychosis – has an incidence of 0.14 % - 0.26 %. It occurs in the first 3 months postpartum.
Symptoms:
- Agitation
- Hyperactivity
- Insomnia
ALDERSGATE COLLEGE NCM 107A
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

- Mood lability
- Confusion
- Irrational thoughts and behaviors
- Difficulty remembering and concentrating
- Poor judgments
- Delusions
- Hallucinations
Risk Factors:
- Previous puerperal psychosis
- History of bipolar disorder
- Prenatal stressors
- Obsessive personality
- Family history and mood disorder
Treatment
- Hospitalization
- Antipsychotic drugs
- Sedatives
- Electro-Convulsive Therapy
- Removal of infant from care of mother
- Social support
- Psychotherapy

3. Postpartum Major Mood Disorders (Postpartum Depression) – develops in about 8-20 % of all postpartum
mothers. It occurs around the 4th week postpartum, just prior to the initiation of menses and upon weaning. The
duration may extend up to 6 months.
Symptoms:
- Sadness
- Frequent insomnia or excessive sleeping
- Frequent crying
- Appetite changes
- Difficulty concentrating and making decisions
- Feelings of worthlessness
- Obsessive thoughts of inadequacy as a person and as a parent
- Lack of interest in daily activities
- Lack of concerns about personal appearance
- Irritability and hostility towards others
Risk Factors
- Primiparity
- Ambivalence about maintaining pregnancy
- History of depression and bipolar illness
- Previous postpartum depression
- Family history of psychiatric disorders
- Lack of social support
- Lack of stable relationship with parents or patners
- The woman’s dissatisfaction with herself, including body image problems and eating disorders
- Lack of supportive relationship with her parents, especially her father as a child
Treatment
- Medication
- Individual or group psychotherapy
- Practical assistance with child care
- Hospitalization at a psychiatric unit if depression continues.

Postpartal Assessment Summary

B – Breast – nipples, breastmilk
ALDERSGATE COLLEGE NCM 107A
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

U – Uterus – involution, fundic height, consistency

B – Bladder – urinary output, distention, hematuria
B – Bowel – constipation, flatulence
L – Lochia – types, amount, color, presence of clots
E – Episiotomy – presence of infection, pain, redness
H – Homan’s Sign – test for deep vein thrombosis
E – Emotional State – psychological conditions, adaptations
R – Rhogam (Rh Immune Globulin) – is given to mothers who are Rh negative who carries an Rh positive

General Postpartal Care

A. Immediate Care

1. Observe carefully for bleeding during the first 6 hours after labor and during the first hour postpartum.
2. Palpate fundus of uterus to assure it remains firm, round and contracted.
3. Mother should be kept clean and dry during the first hour but should be allowed to rest as much as
possible.

B. General Physical Care

1. Vital signs monitoring
2. Nutrition
3. Rest and sleep
4. Early ambulation
5. Bathing
6. Elimination
7. Breast care
ALDERSGATE COLLEGE NCM 107A
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

8. Perineal care
9. Abdominal support
10. Lactation